Guidelines 2000 for colon and rectal cancer surgery

Estándares de calidad de la cirugía del cáncer de recto

The results of surgery for rectal cancer have classically been measured through indicators such as morbidity, mortality, and length of hospital stay. In the last few years other parameters have been included that evaluate healthcare quality such as the functional results of the surgical technique employed and quality of life. Total resection of the mesorectum, performed by experienced surgeons, is the surgical technique of choice. Currently, the sphincter can be preserved in 70% of patients. Anastomotic dehiscence after anterior resection of the rectum is the most serious complication and the most important risk factor is the height of the anastomosis. The overall dehiscence rate should be less than 15% and operative mortality should be between 2% and 3%. The colonic reservoir improves functional outcome and consequently it is the procedure of choice to reconstruct transit after low anterior resection. Local recurrence should be less than 10% and 5-year survival should be between 70% and 80%. In general, quality of life is better after anterior resection of the rectum than after abdominoperineal amputation, despite the functional deterioration presented by some patients.

Lymph node micrometastasis in stage II distal rectal cancer following neoadjuvant chemoradiation therapy

OBJECTIVE

The objective was to determine the presence and frequency of micrometastasis in lymph nodes of patients with rectal cancer treated by preoperative chemoradiation followed by curative resection.

PATIENTS AND METHODS

All 56 patients included were treated with 5-FU and leucovorin plus 5,040 cGy, followed by radical surgery and were diagnosed with stage II distal rectal adenocarcinoma after complete pathological examination (ypT3-4N0M0). Immunohistochemistry was assessed with cytokeratin monoclonal antibody AE1/AE3. Three 4-microm paraffin sections were obtained from each lymph node, cut at 50 microm apart from each other. The results were reviewed by two independent pathologists.

RESULTS

Mean number of lymph nodes was 9.6 per patient. Four patients (7%) and seven lymph nodes (1.35%) were positive for micrometastasis. Three patients had pT3 and one a pT4 tumor. One of the patients had positive micrometastasis and the presence of mucinous deposits. One other patient had mucinous deposits without any micrometastasis. All four patients are alive with no evidence of recurrent disease. Fourteen patients negative for micrometastasis had recurrent disease (25%), eight systemic (14.7%) and six locoregional (10.3%). There were two cancer-related deaths. The mean follow-up period was 39 months.

CONCLUSION

Patients with rectal cancer treated by preoperative chemoradiation showed a surprisingly low rate of micrometastasis detection (7%), even in high-risk patients (T3 and T4 tumors). Lymph node micrometastasis was not associated with decreased overall or disease-free survival. The identification of mucinous deposits on lymph nodes with no viable tumor cells may be direct evidence of lymph node downstaging. The downstaging effect of preoperative chemoradiation therapy may be significant in reducing even micrometastasis detection in low rectal cancer managed by this treatment strategy.

Oxaliplatin, a Potent Inhibitor of Survivin, Enhances Paclitaxel-induced Apoptosis and Mitotic Catastrophe in Colon Cancer Cells

BACKGROUND

Clinical studies have demonstrated that oxaliplatin, a novel platinum derivative, is a potent chemotherapeutic agent, especially when combined with other reagents. The aim of the present study was to explore the mechanism of such action.

METHODS

Using colon cancer cell lines, we examined changes in cell cycle, apoptosis and mitotic catastrophe induced by oxaliplatin and/or paclitaxel.

RESULTS

Oxaliplatin at its IC(50) induced apoptosis and cell cycle arrest at G(2)-M phase. Western blot analyses indicated that oxaliplatin decreased mitosis-commencing protein cdc2 and anti-apoptotic proteins, phospho-Bcl(2) and Bcl-xl in the three colon cancer cells tested. Since cdc2 stabilizes survivin, a putative IAP (inhibitor of apoptosis) family member, through phosphorylation of Thr34, we examined the level of survivin and found a marked decrease due to oxaliplatin. This finding is of particular interest because survivin is a promising molecular target against various human cancers and a key molecule involved in both apoptosis and mitotic catastrophe. When used in combination with paclitaxel (taxol), a putative apoptosis-inducing reagent, the isobologram indicated that the taxol-oxaliplatin sequence or taxol plus oxaliplatin had synergic or additive effects, while the oxaliplatin-taxol sequence resulted in a prominent antagonism. The taxol-oxaliplatin sequence caused marked growth inhibition of DLD1 and SW480 cells, possibly due to upregulation of apoptotic and non-apoptotic pathways, respectively. Morphological surveys indicated that the non-apoptotic process could be mitotic catastrophe.

CONCLUSION

Our results suggest that oxaliplatin that potently inhibited survivin may exert outstanding cytotoxic effects when combined with certain chemoreagents through enhancement of apoptosis and mitotic catastrophe.

Laparoscopic surgery versus open surgery for colon cancer: short-term outcomes of a randomised trial

BACKGROUND

The safety and short-term benefits of laparoscopic colectomy for cancer remain debatable. The multicentre COLOR (COlon cancer Laparoscopic or Open Resection) trial was done to assess the safety and benefit of laparoscopic resection compared with open resection for curative treatment of patients with cancer of the right or left colon.

METHODS

627 patients were randomly assigned to laparoscopic surgery and 621 patients to open surgery. The primary endpoint was cancer-free survival 3 years after surgery. Secondary outcomes were short-term morbidity and mortality, number of positive resection margins, local recurrence, port-site or wound-site recurrence, metastasis, overall survival, and blood loss during surgery. Analysis was by intention to treat. Here, clinical characteristics, operative findings, and postoperative outcome are reported.

FINDINGS

Patients assigned laparoscopic resection had less blood loss compared with those assigned open resection (median 100 mL [range 0-2700] vs 175 mL [0-2000], p<0.0001), although laparoscopic surgery lasted 30 min longer than did open surgery (p<0.0001). Conversion to open surgery was needed for 91 (17%) patients undergoing the laparoscopic procedure. Radicality of resection as assessed by number of removed lymph nodes and length of resected oral and aboral bowel did not differ between groups. Laparoscopic colectomy was associated with earlier recovery of bowel function (p<0.0001), need for fewer analgesics, and with a shorter hospital stay (p<0.0001) compared with open colectomy. Morbidity and mortality 28 days after colectomy did not differ between groups.

INTERPRETATION

Laparoscopic surgery can be used for safe and radical resection of cancer in the right, left, and sigmoid colon.

Distribution of lymph node metastasis in T1 sigmoid colon carcinoma: should we ligate the inferior mesenteric artery?

OBJECTIVE

In standard oncological sigmoid colectomy, the inferior mesenteric artery is ligated either at its origin or at the level of the left colic artery. However, in patients with early-stage carcinoma, the distribution of metastatic nodes may be limited. The aim of this study was to clarify the prevalence and distribution of lymph node metastasis in T1 sigmoid colon carcinoma and to determine the adequate range of lymph node dissection.

MATERIALS AND METHODS

The study included 121 consecutive patients treated for T1 sigmoid colon carcinoma. Clinicopathologic factors associated with nodal metastasis and the distribution of metastatic nodes were analyzed.

RESULTS

Of 121 patients, 12 (10%) had nodal involvement. The depth of invasion and the presence of lymphatic and vascular invasion were significantly associated with nodal metastasis. Of these 12 patients, 11 (92%) had lymph node metastasis confined to pericolic nodes. Nodes along the sigmoidal artery were involved in one patient. There was no involved node along the superior rectal artery or at the root of the inferior mesenteric artery.

CONCLUSIONS

Lymph node dissection for T1 sigmoid colon carcinoma should be limited to the root of the sigmoidal artery, and the inferior mesenteric artery should be preserved.

Anterior resection of rectal cancer through a one hand-size incision with or without laparoscopy: proposal of one hand-size incision surgery (OHaSIS)

BACKGROUND

One hand-size incision surgery (OHaSIS) is a surgery that is carried out through one hand-size incision with or without laparoscopy. Safety, feasibility and recovery advantage of the anterior resection of rectal cancer by the OHaSIS were studied.

STUDY DESIGN

Nineteen consecutive patients with rectal cancer, consisting of seven rectosigmoid, six upper rectal, and six lower rectal cancers, were treated with anterior resection, including seven high, six low, three super-low, and three partial intersphincteric resections, through a suprapubic longitudinal one hand-size incision. The initial 11 patients were treated in combination with laparoscopy and the following eight patients were treated without laparoscopy.

RESULTS

All anterior resections with mesorectal excision were completed in a safe manner with acceptable operative time (average 245 min), blood loss (average 280 g), and postoperative complications without any elongation of the initial incision. When compared with 12 previous high and low anterior resections by conventional open surgery (OS), the 13 high and low anterior resections by the OHaSIS showed equivalent operative time, blood loss, anastomotic procedures of single stapling, lymph node numbers dissected, surgical margin of the anal side of the tumor, and complications. Moreover, analysis of perioperative parameters for surgical invasiveness, including a body temperature >37 degrees C, days of bed rest, and days of use of parenteral narcotics, revealed a recovery advantage in the OHaSIS group compared with that in the OS group.

CONCLUSIONS

These results suggest that anterior resection for patients with rectal cancer by the OHaSIS is safe, feasible, and less invasive than conventional OS, and has sufficient operative performance. Although the survival benefit and recurrence rate by this approach must be ensured in a future trial, we would like to propose the new concept of OHaSIS for treating rectal cancer.

Phase III Southwest Oncology Group 9415/Intergroup 0153 randomized trial of fluorouracil, leucovorin, and levamisole versus fluorouracil continuous infusion and levamisole for adjuvant treatment of stage III and high-risk stage II colon cancer

PURPOSE

Modest toxicity and possibly enhanced activity makes continuous-infusion fluorouracil (FU) an attractive alternative to FU plus leucovorin (FU/LV) for the adjuvant treatment of colorectal cancer. Intergroup trial 0153 (Southwest Oncology Group trial 9415) was developed to compare the efficacy of continuous-infusion FU (CIFU) plus levamisole to FU/LV plus levamisole in the adjuvant treatment of high-risk Dukes' B2 and C1 or C2 colon cancer.

PATIENTS AND METHODS

After surgery, patients were randomly assigned to CIFU 250 mg/m(2)/d for 56 days every 9 weeks for three cycles or FU 425 mg/m(2) and LV 20 mg/m(2) daily for 5 days every 28 to 35 days for six cycles. All patients received levamisole 50 mg tid for 3 days every other week. The primary end point was overall survival (OS).

RESULTS

The study closed in December 1999 after an interim analysis demonstrated little likelihood of CIFU showing superiority to FU/LV within the stipulated hazard ratio. A total of 1,135 patients were registered. At least one grade 4 toxicity occurred in 39% of patients receiving FU/LV and 5% of patients receiving CIFU. However, almost twice as many patients receiving CIFU discontinued therapy early compared with those receiving FU/LV. The 5-year OS is 70% (95% CI, 66% to 74%) for FU/LV and 69% (95% CI, 64% to 73%) for CIFU. The corresponding 5-year disease-free survival (DFS) is 61% (95% CI, 56% to 65%) and 63% (95% CI, 59% to 68%), respectively. For all patients, 5-year OS is 83%, 74%, and 55%; 5-year DFS is 78%, 67%, and 47% for N0, N1, and N2-3, respectively.

CONCLUSION

CIFU had less severe toxicity but did not improve DFS or OS in comparison with bolus FU/LV.

Laparoscopic colectomy for colon adenocarcinoma: an 11-year retrospective review with 5-year survival rates

BACKGROUND

Laparoscopic colectomy for the management of colon cancer remains a controversial therapeutic option, especially when the outcomes are compared with the historically accepted survival data and recurrence rates after open surgery. The purpose of this study was to evaluate the 5-year overall and disease-free survival rates after laparoscopic colon resection for invasive colon adenocarcinoma.

METHODS

A total of 129 patients underwent consecutive laparoscopic colectomies for colon adenocarcinoma (between April 1992 and 2004 January) by a single surgeon at a single institution. Records were analyzed retrospectively and follow-up data was obtained. The Student t-test, Cox regression analysis, and Kaplan-Meier survival data were used for statistical analysis.

RESULTS

After patients with noninvasive disease on final pathology were excluded, the study population comprised 88 patients who underwent laparoscopic colectomies for invasive colon cancer with > 2 years of follow-up. Of these cases, 81 (93%) were amenable for complete follow-up at 11years (41 women and 40 men; mean age, 76 years). Mean follow-up was 61 months. There was one perioperative death (1.2%), and the overall postoperative morbidity rate was 13.6%. The average number of lymph nodes harvested was 10.1 (+/-6). There were no port site recurrences. The Kaplan-Meier survival data were as follows for 5-year overall survival and 5-year disease-free survival, respectively stage I (n = 34) 89% and 89%; stage II (n = 22), 65% and 59%; stage III (n = 19), 72% and 67%; stages I-III combined, (n = 75), 77% and 73%.

CONCLUSIONS

For this specific cohort of patients undergoing curative laparoscopic colectomies for invasive colon adenocarcinoma, the mean follow-up was > 5 years. Overall survival and disease-free survival for stage I, II, and III colon cancer as well as for stages I-III combined are favorable and comparable to historically acceptable open colectomy survival rates. Overall survival and disease-free survival after laparoscopic colectomy for invasive colon cancer is no worse, and perhaps better than, the previously reported rates for the same procedure done by an open technique.

Number of lymph nodes examined and prognosis of TNM stage II colorectal cancer

The diagnosis of a lymph node-negative colorectal carcinoma should imply a good prognosis; however, the outcomes for TNM stage II patients remain variable. Few studies have examined the relationship of the number of lymph nodes examined to the prognosis of this stage. The aim of this study was to determine whether the number of lymph nodes examined has an effect on prognosis of a relatively large sample of patients undergoing curative surgery for stage II colorectal cancer at a single institution. Data on patients who underwent surgery for colorectal cancer between January 1980 and April 2000 were prospectively collected in a database. Patients with TNM stage II or stage III tumours who were treated with curative intent were removed. Patients over 80 years of age were excluded from the survival analysis. Survival comparisons were made using Kaplan-Meier curves and the log-rank test. Multivariate analysis was performed using a Cox regression model. A total of 625 cases of TNM stage II cases and, for comparison purposes, 415 stage III cases, were analysed. Lymph node retrieval in stage II cases was affected by the patient's age (P=0.04) and gender (P=0.02), tumour grade (P<0.0001), tumour site (P<0.0001), and necessity to carry out extended resection (P<0.0001). In stage III cases, lymph node retrieval was affected by patient age (P<0.0001), tumour grade (P=0.02), and tumour site (P=0.002). Decreased lymph node detection was associated with increasing hazard ratios among the 480 TNM stage II patients under 80 years of age, but not among the 345 patients with TNM stage III tumours. Five year survival rate for patients with stage III tumours with only 1-3 positive lymph nodes (52.6%) was similar to that of patients with stage II tumour who had nine or fewer lymph nodes examined (51.3%). These results demonstrate that the prognosis of TNM stage II colorectal cancer is dependent on the number of lymph nodes examined. Patients with few nodes examined have a poorer prognosis. It is possible that a smaller number of lymph nodes examined reflects a diminished immune response. It can be presumed that those patients with stage II tumour with only a few nodes examined should be offered postoperative chemotherapy on a routine basis.

Impact of preoperative radiation for rectal cancer on subsequent lymph node evaluation: a population-based analysis

PURPOSE

To determine the impact of preoperative radiotherapy (RT) on the accuracy of lymph node staging (LNS). Preoperative RT is a well-established component of rectal cancer treatment but its impact on LNS is unknown.

METHODS AND MATERIALS

The Surveillance, Epidemiology and End Results (SEER) registry, representing 14% of the U.S. population, was used to assess the impact of preoperative RT on LNS. Our study population consisted of adults with rectal cancer between 1998 and 2000 who underwent radical resection.

RESULTS

In our 3-year study period, 5647 patients met the selection criteria and 1034 (19.5%) underwent preoperative RT. The preoperative RT group was younger (average age, 61 years) than those who did not undergo preoperative RT (average age, 69 years) and more likely to be male (22% of men vs. 16% of women). On average, fewer nodes were examined in patients who underwent preoperative RT (7 nodes) vs. those who did not (10 nodes); this difference was statistically significant, controlling for potential confounders (p < or = 0.0001). In 16% of the preoperative RT patients (vs. 7.5% without), no nodes were identified (p < or = 0.0001). If one used a minimum of 12 nodes as the standard, only 20% of patients who underwent preoperative RT underwent adequate LNS.

CONCLUSION

Lymph node staging in patients who undergo preoperative RT must be interpreted with caution. Studies are needed to evaluate the clinical relevance of node number and pathologic staging after preoperative RT for rectal cancer.

Ganglions et cancer du rectum

Nodal invasion is a major prognostic factor of rectal cancer. Lymphatic extension of rectal cancer usually involves the mesorectal nodes then the inferior mesenteric chain but in 14% of patients, particularly with cancer of the lower rectum, metastasic nodes can be observed in the internal or lumboaortic chains situated beyond the usual territory of nodal dissection. On average, 30 nodes are examined on a proctectomy specimen, but with wide interindividual variation. The tumor can be adequately staged if at least 15 nodes are examined with little risk of not recognizing nodal metastasis. Metastatic nodes of rectal cancer are almost always small, more than 90% measuring less than 10 mm and 70% less than 5 mm. The number of invaded nodes and the total number of examined nodes are prognostic factors for survival. Hypofrationated preoperative radiotherapy does not alter the nodal status but a long radiotherapy protocol (45 Gy over 5 weeks) reduces significantly the total number of nodes examined without changing the number of metastasic nodes. Micrometastases (measuring less than 2 mm), identified by immunohistochemistry or gene amplification, can be detected in 25 to 70% of nodes considered metastasis-free at the usual microscopic examination. The prognostic value of these micrometastases remains to be established. The first node draining the tumor (sentinel node), which can be detected rapidly with dye infusion, appears to provide a good picture of the nodal status, the risk of finding an invaded node if the sentinel node is metastasis-free is less than 5%.

Practice parameters for the management of rectal cancer (revised)

The American Society of Colon and Rectal Surgeons is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Standards Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This Committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive, and not prescriptive. Their purpose is to provide information on which decisions can be made, rather than dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, health care workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient.

Aktuelle Behandlungsstrategien beim Rektumkarzinom

In the last ten years, considerable progress has been achieved in the treatment of rectal cancer. According to improved interdisciplinary staging, rectal carcinomas can be treated based on a stage-dependent concept: "low-risk" pT1 (G1/G2) carcinomas can be cured by local full wall excision, while "high-risk" pT1 (G3/G4) and pT2 carcinomas require transabdominal resection. In contrast, locally advanced rectal cancers in cUICC-II/-III stages (T3/T4 or N(+)) should receive long-term, 5-FU-based, neoadjuvant chemoradiotherapy according to the excellent results of the CAO/AIO/ARO-94 trial of the German Rectal Cancer Study Group. High-quality resection must be based on radical oncologic principles such as "no-touch" technique, radicular dissection of vessels, and total mesorectal excision. Multimodal treatment is completed with adjuvant 5-FU-based chemotherapy. This therapeutic approach led to a reduction in the 5-year local recurrence rate to 6% and disease-free survival of approximately 68% in advanced rectal cancer (overall survival: 76%).

Thin-Section MRI with a Phased-Array Coil for Preoperative Evaluation of Pelvic Anatomy and Tumor Extent in Patients with Rectal Cancer

OBJECTIVE

The aim of our study was to assess the accuracy of thin-section MRI performed with a phased-array coil as a technique for the preoperative evaluation of pelvic anatomy and tumor extent in patients with rectal cancer.

CONCLUSION

Thin-section MRI with a phased-array coil is accurate and reliable for preoperative evaluation of pelvic anatomy and depth of transmural tumor invasion. Thus, it may be helpful in the selection of the appropriate treatment for patients with rectal cancer.

Lymph Node Evaluation in Colorectal Cancer Patients: A Population-Based Study

BACKGROUND

Adequate lymph node evaluation is required for proper staging of colorectal cancer, and the number of lymph nodes examined is associated with survival. According to current guidelines, the recommended minimum number of lymph nodes examined to ensure adequate sampling is 12. We used data from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the proportion of colorectal cancer patients in the United States who receive adequate lymph node evaluation.

METHODS

For 116,995 adults with colorectal adenocarcinoma, diagnosed from 1988 through 2001, who underwent radical surgery and did not receive neoadjuvant radiation, we evaluated the number of lymph nodes, the likelihood of receiving adequate lymph node evaluation (i.e., at least 12 lymph nodes examined), and the influence of tumor and patient factors on lymph node evaluation. All statistical tests were two-sided.

RESULTS

Among all patients, the median number of lymph nodes examined was nine. Only 37% of all patients received adequate lymph node evaluation. The proportion of patients receiving adequate lymph node evaluation increased from 32% in 1988 to 44% in 2001 (P(trend)<.001, Cochran-Armitage test). Advanced tumor stage was statistically significantly associated with adequate lymph node evaluation (odds ratio [OR] of receiving adequate lymph node evaluation=2.27, 95% confidence interval [CI] = 2.18 to 2.35). Older patients (> or =71 years, OR = 0.45, 95% CI = 0.44 to 0.47) were less likely to receive adequate lymph node evaluation than younger patients, and those with left-sided (OR = 0.45, 95% CI = 0.44 to 0.47) or rectal (OR = 0.52, 95% CI = 0.50 to 0.54) cancers were less likely to receive adequate lymph node evaluation than patients with right-sided cancers. In all analyses, geographic location was an important predictor of adequate lymph node evaluation, which ranged from 33% to 53%, depending on geographic location.

CONCLUSIONS

In 2001, the majority of patients with colorectal cancer still received inadequate lymph node evaluation. The association of demographic variables, particularly patient age and geographic location, with adequate lymph node evaluation indicates that local surgical and pathology practice patterns may affect adequacy of lymph node evaluation.

Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model

BACKGROUND

The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation.

METHODS

A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7.

RESULTS

Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers.

CONCLUSIONS

This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.

Learning curve: the surgeon as a prognostic factor in colorectal cancer surgery

The individual surgeon is an independent prognostic factor for outcome in colorectal cancer surgery. The surgeon's learning curve is therefore directly related to the patient's outcome. The exact shape of the learning curve, however, is unknown. The present study reviewed supervision, training/teaching, specialization, surgeon's caseload, and hospital's caseload as the five main surgeon- and hospital-related confounding factors for outcome, and examined their influence on the learning curve as well as their interactions and prognostic significance. All five confounding factors were related to outcome. The highest degree of evidence, however, was found for training/teaching (introduction of total mesorectal excision), specialization in colorectal surgery (special interest, board-certification, specialized colorectal cancer units), and the surgeon's caseload. Five surgeon- and hospital-related factors directly influence the surgeon's learning curve and are therefore rightly considered predictors of outcome in colorectal cancer surgery. Improvements in supervision, training/teaching, specialization, the surgeon's caseload, and the hospital's caseload will therefore translate into enhanced patient outcome.

Surgical results of total mesorectal excision for rectal cancer in a specialised colorectal unit

Our aim was to review the results of total mesorectal excision (TME) in a specialised colorectal unit. Perioperative and follow-up data were prospectively collected in a computerised database. A review of all the records was made. The morbidity rate was about 14%, and was higher in patients with coloplasty due to a higher anastomotic leak rate. The local recurrence rate was 2%, the distant metastasis rate was 11%, and both local and distant metastasis occurred in 4%. About 95% of recurrence occurred within 3 years. There was better bowel function in patients with a colonic J-pouch in the first 2 years after surgery, but the advantage disappeared thereafter. There were no differences in function between descending and sigmoid colonic J-pouches. TME in a specialised colorectal unit has low morbidity and mortality. Our procedure of choice is that of a sigmoid colon J-pouch anal anastomosis.

Laparoscopic versus open total mesorectal excision for rectal cancer: An evaluation of the mesorectum’s macroscopic quality

BACKGROUND

Next to surgical margins, yield of lymph nodes, and length of bowel resected, macroscopic completeness of mesorectal excision may serve as another quality control of total mesorectal excision (TME). In this study, the macroscopic completeness of laparoscopic TME was evaluated.

METHODS

A series of 25 patients with rectal cancer were managed laparoscopically (LTME) and included in this study. The pathologic specimens of the LTME group were prospectively examined and matched with a historical group of resection specimens from patients who had undergone open TME (OTME). The two groups were matched for gender and type of resection (low anterior or abdominoperineal resection). Special care was given to the macroscopic judgment concerning the completeness of the mesorectum.

RESULTS

A three-grade scoring system showed no differences between the LTME and OTME groups.

CONCLUSION

The current study supports the hypothesis that oncologic resection using laparoscopic TME is feasible and adequate.

Cyclooxygenase-2 Expression

PURPOSE

Recent studies have shown that cyclooxygenase (Cox)-2 may be involved in colorectal carcinogenesis. We aimed to determine whether Cox-2 expression in itself can predict outcome of colorectal cancer patient after surgery. In addition, the expression of Cox-1 was also evaluated.

EXPERIMENTAL DESIGN

Tissue samples of primary and secondary tumors from 288 patients undergoing surgical resections for colorectal adenocarcinoma were immunohistochemically examined for Cox-2 and Cox-1 expressions. The specimens were graded based on the intensity and extent of staining; then, the correlations between Cox-2 and Cox-1 expressions with clinicopathologic parameters and survival time were analyzed.

RESULTS

Expression of Cox-2 was positive in 70.8% of primary tumor, 92.0% of lymph node metastases, 100.0% of hepatic metastases, and was significantly associated with tumor size, depth of invasion, lymph node metastasis, vessels invasion, stage and recurrence. In contrast, Cox-1 was positive in 42.7% of primary tumor, 84.0% of lymph node metastases, 37.5% hepatic metastases, and was associated with only tumor size. Patients with Cox-2-positive tumors had a significant shorter survival time than those with negative tumors did (P = 0.0006 by log-rank test); and, in a multivariate analysis, Cox-2 was an independent prognostic factor (P = 0.0103; relative risk 4.114; 95% confidence interval, 1.397-12.120). Cox-1 status had no statistically effect on patient survival time.

CONCLUSIONS

Elevated Cox-2 expression, but not that of Cox-1, was significantly associated with reduced survival and recognized as an independent prognostic factor in our cohort of colorectal cancer patients.

Comparison of multivisceral resection and standard operation for locally advanced colorectal cancer: analysis of prognostic factors for short-term and long-term outcome

PURPOSE

The aim of the present study is to clarify the characteristics of multivisceral resection and to discuss strategies for improving the overall outcome of multivisceral resection for locally advanced colorectal cancer.

METHODS

The study included 323 patients who electively underwent curative surgery for pT3-pT4 colorectal carcinoma without distant metastasis. We evaluated the short-term and long-term outcome of multivisceral resection relative to that of the standard operation by means of multivariate analysis of the prognostic factors.

RESULTS

Of 323 patients, 53 (16.4 percent) received multivisceral resection because of adhesion to other organs. Multivisceral resection was significantly associated with tumor size, depth of invasion, operative blood loss, operation time, and blood transfusion (all: P < 0.0001). Overall morbidity rates were 49.1 percent after multivisceral resection vs. 17.8 percent after the standard operation (P < 0.0001), and postoperative mortality rate was 0 percent in both groups (not significant). Only multivisceral resection (odds ratio, 2.725; 95 percent confidence interval, 1.125-6.623; P = 0.0264) was an independent factor for overall postoperative complications. The survival rate of patients after multivisceral resection was similar to that after the standard operation (5-year rate, 76.6 percent vs. 79.5 percent, P = 0.9347). Lymph node metastasis (hazard ratio, 2.510; 95 percent confidence interval, 1.460-4.315; P = 0.0009) and blood transfusion (hazard ratio, 2.353; 95 percent confidence interval, 1.185-4.651; P = 0.0145) were independently associated with patient survival.

CONCLUSIONS

For locally advanced colorectal cancer, the long-term outcome after multivisceral resection is comparable to that after the standard operation. However, it should be recognized that multivisceral resection is associated with higher postoperative morbidity. In addition, a reduction in the incidence of blood transfusion may contribute to improving patient survival.

Evidence-based practice requires evidence

Patient Safety Leading Article Series, 2004. Continuing the Journal's ‘Patient Safety’ series, David Rothenberger explains why we must transform our culture to become a genuinely evidence-seeking profession.

Complete remission of primary colon cancer in a metastatic patient treated with CPT-11 plus capecitabine

BACKGROUND AND AIMS

The best treatment of patients with advanced colorectal cancer at the time of diagnosis is not well known, and the medical treatment is still unsatisfactory.

CASE PRESENTATION

We report the case of a patient showing a complete remission of primary tumor after medical therapy with CPT-11 plus capecitabine.

DISCUSSION

The best management of advanced disease at first presentation is discussed.

Colon cancer survival rates with the new American Joint Committee on Cancer sixth edition staging

BACKGROUND

The recently revised American Joint Committee on Cancer (AJCC) sixth edition cancer staging system increased the stratification within colon cancer stages II and III defined by the AJCC fifth edition system. Using nationally representative Surveillance, Epidemiology, and End Results (SEER) data, we compared survival rates associated with colon cancer stages defined according to both AJCC systems.

METHODS

Using SEER data (from January 1, 1991, through December 31, 2000), we identified 119,363 patients with colon adenocarcinoma and included all patients in two analyses by stages defined by AJCC fifth and sixth edition systems. Tumors were stratified by SEER's "extent of disease" and "number of positive [lymph] nodes" coding schemes. Kaplan-Meier analyses were used to compare overall and stage-specific 5-year survival. All statistical tests were two-sided.

RESULTS

Overall 5-year survival was 65.2%. According to stages defined by the AJCC fifth edition system, 5-year stage-specific survivals were 93.2% for stage I, 82.5% for stage II, 59.5% for stage III, and 8.1% for stage IV. According to stages defined by the AJCC sixth edition system, 5-year stage-specific survivals were 93.2% for stage I, 84.7% for stage IIa, 72.2% for stage IIb, 83.4% for stage IIIa, 64.1% for stage IIIb, 44.3% for stage IIIc, and 8.1% for stage IV. Under the sixth edition system, 5-year survival was statistically significantly better for patients with stage IIIa colon cancer (83.4%) than for patients with stage IIb disease (72.2%) (P<.001).

CONCLUSIONS

The AJCC sixth edition system for colon cancer stratifies survival more distinctly than the fifth edition system by providing more substages. The association of stage IIIa colon cancer with statistically significantly better survival than stage IIb in the new system may reflect current clinical practice, in which stage III patients receive chemotherapy but stage II patients generally do not.

Identification of patients with high-risk lymph node-negative colorectal cancer and potential benefit from adjuvant chemotherapy

BACKGROUND

Adjuvant chemotherapy is not indicated in lymph node-negative colorectal adenocarcinoma (CRC), even though some cases will present recurrent disease. It is important to identify a subgroup of patients with the highest risk of relapse because of the potential benefit of adjuvant chemotherapy. The objective of this study is to define the prognostic factors and describe a method for the selection of this subgroup.

METHODS

A retrospective cohort of 124 patients with lymph node-negative CRC with complete surgical resection was studied. Cox's proportional hazards model was used to define the prognostic factors associated with CRC-related survival and to develop a method for prediction of recurrence probability.

RESULTS

The cohort included 62 women and 62 men with mean age 55.8 years. The mean follow-up period was 11.7 years. T classification of the primary tumor, differentiation grade, carcinoembryonic antigen level, gender and the presence of neural invasion were significant prognostic factors according to the multivariate analysis (final model P=0.00001). Using risk ratios for these prognostic factors, we defined a high-risk group of 78 patients and a low-risk group of 46 patients with 24 and 5 recurrences, respectively (recurrence rates of 30.8% and 10.9% respectively, P=0.011).

CONCLUSIONS

Using these factors, a prognostic scale was developed to predict high risk of recurrence in cases of completely resected CRC and to identify them as a subgroup of patients with potential benefit of adjuvant chemotherapy.

Sentinel lymph node mapping in colon cancer

BACKGROUND

By systematically reviewing the literature on sentinel lymph node mapping of colon cancers, this study aimed to evaluate this technique as it applies to colon cancers.

METHODS

Human studies on lymphatic mapping for colon cancers were reviewed. Multiple publications of the same studies, abstracts, and case reports were excluded. Current Contents, MEDLINE, EMBASE, and Cochrane Library databases were investigated.

RESULTS

Lymphatic mapping appears to be readily applicable to colon cancers, identifying lymph nodes most likely to harbor metastases. Identification of sentinel lymph nodes varied from 58% to 100% and carried a false-negative rate of approximately 10% in larger studies, but potentially rose 4% to 25% among patients representing a range from node-negative to node-positive (micrometastases) conditions. The prognostic implication of these micrometastases requires further evaluation. Lymphatic mapping in 6% to 29% of cases identified aberrant lymphatic drainage that altered the extent of the lymphadenectomy.

CONCLUSIONS

Further follow-up evaluation to assess the prognostic significance of micrometastases for colon cancers is required before the staging benefits of sentinel node mapping can have therapeutic implications. Lymphatic mapping offers the possibility of improving staging by identifying patients with early disseminated disease who should be considered for adjuvant treatment or included in trials of adjuvant treatment to speed up the breakthrough of more effective adjuvant regimens. Large studies are needed to determine whether the sentinel node concept is as valid for colon cancers as studies so far have shown it is for malignant melanoma and breast cancer.

Use of surgery among elderly patients with stage IV colorectal cancer

PURPOSE

The role of surgery to remove the primary tumor among patients with stage IV colorectal cancer (CRC) is controversial. The purpose of this study was to evaluate surgical practice patterns for patients > or = 65 years of age with stage IV CRC in a US population-based cohort.

PATIENTS AND METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare-linked database to evaluate the patterns of cancer treatment for 9,011 Medicare beneficiaries presenting with stage IV CRC from 1991 to 1999. Patients were categorized according to whether they had primary-cancer-directed surgery (CDS) or no CDS within 4 months of diagnosis. The use of other treatment modalities, including metastasectomy, chemotherapy, and radiation, was evaluated in relationship to whether patients belonged to the CDS or no CDS group.

RESULTS

Seventy-two percent (6,469 of 9,011) of patients received CDS, and their 30-day postoperative mortality was 10%. Patients with left-sided or rectal lesions, patients older than age 75 years, blacks, and those of lower socioeconomic status were less likely to undergo CDS; but even among those older than age 75, the CDS rate was 69% (3,378 of 4,909). In contrast, chemotherapy use was less common (47% for patients who had CDS and 31% for those who did not). Metastasectomy was rare; only 3.9% of patients underwent these operations at any point from diagnosis to death.

CONCLUSION

Palliative resection of the primary tumor is often performed for elderly US patients with stage IV colorectal cancer. This practice pattern merits re-evaluation, given the improvement in the efficacy of systemic chemotherapy.

Laparoscopic surgery for colorectal cancer: the state of the art

Laparoscopic techniques have expanded since their introduction 15 years ago. The laparoscopic approach for colorectal surgery has been slower to develop than other fields of surgery. However, this approach does provide significant benefits for colorectal resection, although concerns regarding the ability to satisfy oncological criteria have restricted its use in the past. This review studies the published data on the use of laparoscopic surgery for colorectal cancer including the short- and long-term outcomes. New long-term outcome data is now available which is likely to encourage the use of this technique for colon cancer resection. Laparoscopic rectal cancer resection is also discussed including the more limited outcome data that is available.

Validation of ex vivo lymphatic mapping in hematoxylin-eosin node-negative carcinoma of the colon and rectum

BACKGROUND

Substantial evidence supports that detailed analysis of the regional lymphatics will identify previously unrecognized micrometastatic disease in colorectal cancer. In order to determine whether the sentinel lymph node(s) (SLNs) harvested by ex vivo lymphatic mapping in node-negative colorectal cancer (CRC) are the most likely node(s) to harbor micrometastatic disease, we examined all nodes in CRC specimens in an identical fashion.

METHODS

One hundred twenty-four specimens from patients with colorectal cancer were delivered to pathology in the fresh state and underwent ex vivo sentinel lymph node mapping. If negative by routine hematoxylin and eosin (H&E) analysis, the SLNs and non-SLNs were subjected to further analysis by level section H&E and immunohistochemical (IHC) analysis.

RESULTS

A mean of 30 nodes were harvested (range, 5-111). Fifty-one patients (41%) were found to be node-positive by routine H&E analysis. SLNs were identified in all but three specimens. A total of 2177 nodes were analyzed from the 66 H&E node-negative specimens (1883 non-SLNs and 294 SLNs). Overall, metastases were identified in 13 of 278 SLNs and in only 5 of 1829 non-SLNs (P <.001). Only 5 of 66 patients (7.5%) had evidence of metastatic disease in non-SLNs when the SLNs were negative. Thirteen apparently node-negative patients (19.3%) were upstaged by IHC analysis of the SLNs (P =.04).

CONCLUSIONS

If the SLN is negative by both H&E and IHC analysis, the probability of finding metastases in a non-SLN is remote. If microstaging is demonstrated to be prognostically relevant, focused examination should be of the SLN(s).

Laparoscopic resection of colon Cancer: Consensus of the European Association of Endoscopic Surgery (EAES)

BACKGROUND

The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on the laparoscopic resection of colon cancer during the annual congress in Lisbon, Portugal, in June 2002.

METHODS

A systematic review of the current literature was combined with the opinions, of experts in the field of colon cancer surgery to formulate evidence-based statements and recommendations on the laparoscopic resection of colon cancer.

RESULTS

Advanced age, obesity, and previous abdominal operations are not considered absolute contraindications for laparoscopic colon cancer surgery. The most common cause for conversion is the presence of bulky or invasive tumors. Laparoscopic operation takes longer to perform than the open counterpart, but the outcome is similar in terms of specimen size and pathological examination. Immediate postoperative morbidity and mortality are comparable for laparoscopic and open colonic cancer surgery. The laparoscopically operated patients had less postoperative pain, better-preserved pulmonary function, earlier restoration of gastrointestinal function, and an earlier discharge from the hospital. The postoperative stress response is lower after laparoscopic colectomy. The incidence of port site metastases is <1%. Survival after laparoscopic resection of colon cancer appears to be at least equal to survival after open resection. The costs of laparoscopic surgery for colon cancer are higher than those for open surgery.

CONCLUSION

Laparoscopic resection of colon cancer is a safe and feasible procedure that improves short-term outcome. Results regarding the long-term survival of patients enrolled in large multicenter trials will determine its role in general surgery.

New Tumor-Node-Metastasis Staging Strategy for Node-Positive (stage III) Rectal Cancer: An Analysis

Purpose

The tumor-node-metastasis system for staging rectal cancer is based on invasion, number of involved nodes, and metastasis. Nodes are classified as N1 or N2 according to the number involved with metastases. Nodal positivity defines stage III regardless of depth of invasion or number of positive nodes. Our purpose was to analyze overall survival when node-positive patients were stratified into three new subsets.

Methods

We analyzed data entered into the National Cancer Data Base for 5,987 stage III patients with rectal cancer between 1991 and 1993. Survival was calculated using three new subgroups (IIIA: T1/2, N1; IIIB: T3/4, N1; IIIC: any T, N2). Survival following surgery and adjuvant therapy was assessed. The observed survival rates were calculated and compared using the log-rank method. The Cox regression model assessed subgroup differences.

Results

Five-year observed survival rates for stage III subcategories were 55.1% in IIIA; 35.3% in IIIB; and 24.5% in IIIC. Stratifying for treatment outcome, stage IIIA patients having surgery alone (n = 278) had poorer observed 5-year survival (39%) than patients treated with surgery and adjuvant chemotherapy or radiation therapy (chemo/XRT; n = 765; 60%). Similar outcomes occurred in IIIB (surgery-alone [n = 726; 21.7%] and chemo/XRT [n = 2,130; 40.9%] groups) and in IIIC (surgery-alone [n = 467; 12.2%] and chemo/XRT [n = 1,621; 28.9%] groups). Differences were significant (P < .0001) in all stages.

Conclusion

The traditional stage III designation of rectal cancer fails to account for invasion (T1-4) and number of involved nodes (N1, N2). The stratification of stage III patients into three subsets should be used in future analyses of rectal cancer. The effect of postoperative adjuvant therapy was beneficial in all subsets.

Anorectal anatomy and embryology

The anal canal is complex in its anatomy and its embryologic origin. The intricate and changing histology of the anal canal explains the different types of anal cancer. In addition, an understanding of the venous and the lymphatic drainage of the anal canal helps to explain its methods of dissemination. Finally, the basis for the treatment of anal cancer is derived from the cancer's anatomic origins.

The role of lymphadenectomy for liver tumors: further considerations on the appropriateness of treatment strategy

OBJECTIVE

To evaluate the role of regional lymphadenectomy in patients with liver tumors.

BACKGROUND

Lymph node status is 1 of the most important prognostic factors in oncologic surgery; however, the role of lymph node dissection remains unclear for hepatic tumors.

METHODS

A total of 120 consecutive patients undergoing liver resections for primary and secondary hepatic tumors were prospectively enrolled in the study. "Regional" lymphadenectomy was carried out routinely after specimen removal. Incidence, site, and influence on survival of node metastases were analyzed.

RESULTS

Only 1 postoperative complication (intra-abdominal bleeding) was related to lymph node excision. Median number of dissected nodes was 6.8 +/- 3.6. Periportal, pericholedochal, and common hepatic artery stations were always removed. Lymph node metastases were found in 17 (16.5%) patients. The percentage rises to 20.3% when considering only noncirrhotic patients. The incidence of lymph node metastases was 7.5% for hepatocellular carcinoma, 14% for colorectal metastases, 40% for noncolorectal metastases, and 40% for intrahepatic cholangiocarcinoma (P < 0.002). Median survival time was 486 +/- 93.2 days among all patients with node metastases and 725 +/- 29.7 among patients without node metastases. The 2-year survival was 37.1% and 86.7%, in the 2 groups (P < 0.05). The 2-year recurrence rate was 77.6% and 45.3%, respectively (P < 0.05).

CONCLUSIONS

Regional lymphadenectomy is a safe procedure after liver resection, and it should be routinely applied in patients with primary and secondary hepatic tumors, particularly in those without chronic disease. A careful evaluation of node status is nevertheless advisable also in patients with hepatocellular carcinoma on cirrhosis.

Lymph node retrieval and assessment in stage II colorectal cancer: a population-based study

BACKGROUND

Adjuvant chemotherapy for patients with stage III (node-positive) colorectal cancer (CRC) reduces mortality by one third. Retrieval of an inadequate number of lymph nodes in the surgical specimen may result in incorrectly designating some patients as stage II (node negative), and consequently, such patients may not be offered appropriate chemotherapy. Recent National Cancer Institute guidelines suggest that a minimum of 12 nodes should be examined to ensure accurate staging.

METHODS

This population-based study identified stage II (T3N0 and T4N0) CRC cases by using CRC pathology reports (1997-2000) from the Ontario Cancer Registry. Patients aged 19 to 75 years were identified, and demographic, surgical, pathologic, and hospital data were extracted. Factors relating to the number of lymph nodes assessed were examined.

RESULTS

A total of 8848 CRC cases were reviewed, and 1789 stage II cases were identified. Seventy-three percent of cases were designated as node negative on the basis of assessment of <12 lymph nodes. Multivariate analysis showed that age, tumor size, specimen length, use of a pathology template, and academic status of the hospital were significant predictors of the number of lymph nodes assessed.

CONCLUSIONS

A subset of patients with CRC in Ontario were assigned stage II disease on the basis of examination of relatively few lymph nodes.

Hepatic expression of ANG2 RNA in metastatic colorectal cancer

We examined the RNA content of the gene encoding angiopoietin (Ang)-2, a modifier of angiogenesis, in hepatic metastases of colorectal cancer (CRC) to explore the role of this protein in neovascularization of metastatic foci. Metastatic CRC exhibited notable blood flow and tumor vessel formation at tumor frontiers. Reverse-transcription polymerase chain reaction assays indicated that the ANG2 RNA content was greater in metastatic CRC than in primary CRC. Investigation of metastatic foci using laser capture microdissection revealed that the RNA content of ANG2, but not ANG1, increased from the bordering liver region to the periphery of the metastatic disease, and also from the periphery to the intermediate portion of the metastatic lesion; immunohistochemical analysis confirmed that there was a corresponding gradual increase in Ang-2 protein expression. Tie-2, a receptor for angiopoietins, was preferentially expressed in the bordering liver region rather than in metastatic CRC. Vascular endothelial growth factor (VEGF) also exhibited an expression pattern similar to that of Ang-2, and there was a significant correlation between the RNA content of ANG2 and that of VEGF in dissected samples (P =.002). Western blot analysis suggested that expression of Ang-1, Ang-2, Tie-2, and VEGF may be regulated at a transcriptional level. The increase in ANG2 RNA content from the peripheral portion of the tumor to the intermediate portion, coinciding with the decrease in recruitment of periendothelial supporting cells around the vascular endothelial cells, suggests that Ang-2 may play a role in the immaturity of tumor vessels. In conclusion, the current study suggests that Ang-2 and VEGF may cooperate to enhance the formation of new blood vessels in metastases of CRC to the liver.

Lateral pelvic lymph node dissection for advanced lower rectal cancer

BACKGROUND

The oncological outcome of patients who underwent curative surgery for lower rectal cancer was investigated to clarify whether lateral pelvic lymph node dissection (LPLD) conferred any benefit.

METHODS

A total of 246 patients who underwent curative surgery for stage II and III lower rectal cancer (below the peritoneal reflection) between 1985 and 1998 was reviewed. Forty-two of these patients did not undergo LPLD.

RESULTS

Patients who did not undergo LPLD were older, more likely to have anterior resection and pelvic nerve preservation, and had smaller tumours and lymph node metastasis at an earlier stage than those who underwent LPLD. There was no difference in survival among patients with stage II and III disease between the two groups. However, in patients with pathological N1 lymph node metastasis, the 5-year disease-free survival rate was 73.3 per cent in patients who had LPLD compared with 35.3 per cent among those who did not (P = 0.013). Multivariate analysis showed that LPLD was a significant prognostic factor.

CONCLUSION

LPLD improved the prognosis of patients with stage III disease and a small number of lymph node metastases. A randomized clinical trial is needed to verify the benefit of LPLD.

Inadvertent perforation during rectal cancer resection in Norway

Background

Inadvertent perforation of the bowel or tumour is a relatively common complication during resection of rectal cancer. The purpose of this study was to examine intraoperative perforation following the introduction of mesorectal excision as a standard surgical technique in Norway.

Methods

This was a prospective national cohort study of 2873 patients undergoing major resection of rectal carcinoma at 54 Norwegian hospitals from November 1993 to December 1999.

Results

The overall perforation rate was 8·1 per cent (234 of 2873 patients). In a multivariate analysis, the risk of perforation was significantly greater in patients undergoing abdominoperineal resection (odds ratio (OR) 5·6 (95 per cent confidence interval (c.i.) 3·5 to 8·8)) and in those aged 80 years or more (OR 2·0 (95 per cent c.i. 1·2 to 3·5)). The 5-year local recurrence rate was 28·8 per cent following perforation, compared with 9·9 per cent in patients with no perforation (P &lt; 0·001); survival rates were 41·5 and 67·1 per cent respectively (P &lt; 0·001).

Conclusion

The risk of intraoperative perforation was significantly greater in patients with rectal cancer undergoing abdominoperineal resection and in those aged 80 years or more. The high local recurrence rates and reduced survival following perforation call for increased attention to avoid this complication.

Impact of lymph node retrieval and pathological ultra-staging on the prognosis of stage II colon cancer

BACKGROUND AND OBJECTIVES

A minimum number of lymph nodes must be assessed for accurate diagnosis of stage II colon cancer. We assessed number of lymph nodes retrieved, pathological ultra-staging, and outcome in stage II colon cancer.

MATERIALS AND METHODS

Consecutively treated patients with stage II colon cancer were identified. Baseline and outcome data were collected. Retrospective ultra-staging using lymphovascular invasion (LVI) and nodal micrometastases was performed. Patients were divided into two groups: group I had <or=6 nodes and group II had >6 nodes retrieved. Survival was analyzed.

RESULTS

One hundred and fifteen patients were included in the study. The 5 year overall survival was worse in group I versus II (P = 0.03). LVI and micrometastases were identified but neither predicted survival. Disease failure in group I was due to distant metastases rather than local recurrence.

CONCLUSIONS

Inadequate retrieval and assessment of lymph nodes is associated with worse outcome in stage II colon cancer patients. Recurrence patterns support the hypothesis that disease recurrence occurred due to inaccurate staging. In this small study, LVI or nodal micrometastases did not predict survival. Maximal attention should be paid to the total number of lymph nodes retrieved before embarking on potentially more resource intensive staging methods.

The association of pretreatment health-related quality of life with surgical complications for patients undergoing open surgical resection for colorectal cancer

OBJECTIVE

The purpose of this study was to define the association between pretreatment health-related quality of life (HRQL) and surgical complications for patients with colorectal cancer.

SUMMARY BACKGROUND DATA

For patients with colorectal cancer, surgical complications arise from an interaction between underlying medical comorbidity, colorectal cancer severity, and quality and type of treatment provided. Measurement of HRQL provides a summarization of well-being in the context of medical comorbidity and colorectal cancer severity. The summarization of these factors may be useful in prospective risk assessment of patients about to undergo surgery for colorectal cancer.

METHODS

A single-institution, prospective, cohort study of patients with colorectal adenocarcinoma was performed from August 1, 1999, to March 31, 2002. Before treatment, all participants completed Medical Outcomes Survey SF-36 (SF-36); after the first year of the study, patients also completed the colorectal cancer module of the Functional Assessment of Cancer Therapy survey (FACT-C). Information was collected on demographics, treatment, tumor variables, and complications.

RESULTS

Ninety-seven patients have undergone open resection of their colorectal cancer. All patients completed SF-36; 65 completed FACT-C. Thirty patients (31%) experienced complications, including 4 (4%) deaths. Age, race, albumin level, American Society of Anesthesia class, specialty surgical training, tumor location, and stage were not associated with complications in univariate analysis. Patients experiencing surgical complications had significantly lower HRQL scores on SF-36 Social Functioning, General Health Perception, and Mental Health Index scales as well as the Mental Health Component summary score. FACT-C Social/Family, Emotional, Functional Well-Being scores, and the Colorectal Cancer Concerns score were also significantly lower for patients sustaining complications. When these HRQL scales were examined in a multivariate model including albumin level, tumor location, and ASA class, SF-36 Social Functioning (Odds Ratio [OR] = 0.98; 95% Confidence Interval [CI] = 0.97-0.99) and FACT-C Colorectal Cancer Concerns (OR = 0.89; 95% CI = 0.79-0.99) scales retained a significant association with complications.

CONCLUSIONS

Pretreatment HRQL scores as measured by several scales of SF-36 and FACT-C were significantly associated with complications. Future studies should concentrate on defining the predictive role of HRQL in determining surgical outcome for patients with colorectal cancer.

Sphincter saving rectum resection is the standard procedure for low rectal cancer

AIM

To determine the procedure of choice for rectal cancer, particularly low rectal cancer.

METHODS

Complete search, according to evidence-based methods, of comparative studies and national surveys published in English since 1990.

SELECTION CRITERIA

comparative studies between abdominoperineal excision (APER) and sphincter-saving operations (SSO) with a minimum of 50 patients presenting cancer in the lower one-third of the rectum, perfect split of cases with cancer located in the lower, middle or upper one-thirds of the rectum, specified numbers of patients treated by surgery alone or combined with radio-chemotherapy, specified length of follow-up with a minimum of 1 year, univariate or multivariate analysis of prognostic factors. Thirty-four studies fulfilling evidence level C were analyzed, including 6,570 patients.

ENDPOINTS

operative risk, local disease control, disease free or cancer specific survival and quality of life.

RESULTS

Postoperative morbidity after APER and SSO is comparable and postoperative mortality decreased to 2% or less. The type of surgery was not identified as a prognostic factor in terms of local disease control and survival. Quality of life is significantly inferior after APER. National data reveal an APER rate for cancer of the whole rectum (up to 16 cm) at 50% or above, and SSO still would represent only 32% of the radical resections for low rectal cancer.

CONCLUSION

All available evidence indicates that SSO should be the procedure of choice for rectal cancer, even in the lower one-third. An APER should only be performed when cancer invades the anal sphincters and negative resection margins cannot be achieved by a SSO.

Training and quality assurance for rectal cancer: 20 years of data is enough

Rectal cancer is a common disease with a high rate of mortality. During the past 20 years, substantial improvements have been made in the surgical, pathological, radiological, and oncological approaches used to treat this disease, but there is good evidence for continuing suboptimum performances among the teams that treat patients with colorectal cancers. Studies involving more than 4000 patients show that large reductions in local recurrences and a 20% increase in survival can be achieved with high-quality surgical and pathological training in total mesorectal excision. New developments in radiology and oncology may further increase this benefit.

Urinary tract involvement by colorectal cancer

PURPOSE

Involvement of the urinary tract by colorectal cancer is sufficiently rare to be encountered by an individual surgeon on an infrequent basis. The aim of this review is to highlight technical and oncologic issues that should be considered when dealing with complex colorectal cancer that involves the urinary tract.

METHODS

The relevant literature from 1975 to 2001 was identified using the MEDLINE database of the U.S. National Library of Medicine and reviewed. Because of the diversity of forms of presentation of urologic involvement, few randomized, controlled trials are available, with most evidence derived from retrospective studies.

RESULTS

Three distinct clinical situations in which the urinary tract may be affected by colorectal cancer were identified: involvement by primary colorectal cancer, involvement by recurrent cancer, and unexpected intraoperative findings of urinary tract involvement. Management strategies to identify and treat locally advanced primary or recurrent colorectal cancer involving the urinary tract improve survival with acceptable morbidity and mortality. Careful preoperative assessment of all patients with colorectal cancer will reduce unexpected identification of urinary tract invasion at the time of surgery. In patients in whom cure is not possible, endourologic techniques combined with judicious surgical resection can provide high-quality palliation. Optimal care of many of these conditions is facilitated by specialist urologic advice.

CONCLUSIONS

The wide spectrum of possible urinary tract involvement by colorectal cancer requires individual patient-specific and disease-specific consideration. The literature offers important guidelines that aid decision making and improve management of these challenging problems.

The pathological assessment of mesorectal excision: implications for further treatment and quality management

BACKGROUND AND AIMS

Most clinical practice guidelines today recommend total mesorectal excision (TME) for carcinoma of the middle and lower rectal thirds and partial mesorectal excision (PME) for the upper rectal third. However, these procedures may not always fulfill the oncological requirements. The pathological examination of resected rectal carcinomas should always include a visual assessment of the mesorectal excision to ensure oncological adequacy and appropriate quality. The clinical practice guideline of the German Cancer Society recommends reporting of the distal extent of mesorectal excision (total or partial without coning) and the excision in an inviolate fascial envelope.

PATIENTS AND METHODS

Reporting schemas of assessment and documentation for daily use and for studies are presented.

RESULTS

Careful macroscopic evaluation of the resection specimen should be standardized. This may be supplemented by stain marking after postoperative filling the inferior mesenteric or superior rectal artery with ink or methylene blue solution. Photodocumentation is highly desirable. The pathological assessment of adequacy of mesorectal excision should be taken into account in selection for adjuvant radiotherapy. Objective macro- and microscopic assessment of mesorectal excision by pathologists is essential for quality management throughout patient care and in clinical trials.